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纵隔淋巴结纵隔淋巴结 1古柏文档纵隔淋巴结 1古柏文档纵隔淋巴结解剖纵隔淋巴结解剖 特点特点：纵隔淋巴结平均数目为纵隔淋巴结平均数目为6464个，大多数位于气个，大多数位于气管，管，支气管附近和大血管及食道周围支气管附近和大血管及食道周围 主要是位于气管旁的淋巴结主要是位于气管旁的淋巴结A A 主要是位于大血管旁的淋巴结主要是位于大血管旁的淋巴结 主要是位于支气管旁的淋巴结主要是位于支气管旁的淋巴结 P P 主要是位于食管周围淋巴结主要是位于食管周围淋巴结2古柏文档纵隔淋巴结解剖 特点：2古柏文档Classification of Regional Lymph Nodes in Classification of Regional Lymph Nodes in JapanJapanJapan Society of Clinical Oncology(ed),Kanehara,Tokyo,2002.3古柏文档Classification of Regional LymClassification of Regional Lymph Nodes in Classification of Regional Lymph Nodes in JapanJapanJapan Society of Clinical Oncology(ed),Kanehara,Tokyo,2002.4古柏文档Classification of Regional LymClassification of Regional Lymph Nodes in Classification of Regional Lymph Nodes in JapanJapanJapan Society of Clinical Oncology(ed),Kanehara,Tokyo,2002.5古柏文档Classification of Regional Lym6古柏文档6古柏文档 7古柏文档 7古柏文档Mountain and Dresler classification system Schema of Mountain and Dresler classification system 1997年,Mountain 修订了肺癌胸内淋巴分区系统被美国癌症联合会(the American Joint Committee on Cancer,AJCC)和国际抗癌联盟(the Union International Contrele Cancer,U ICC)广泛采纳,但其只是根据外科解剖情况定义各组淋巴结界线,并未在横断面上详细描述各组淋巴结的边界。Chest 1997;111;1718-17238古柏文档Mountain and Dresler classific Mountain and Dresler classification systemn nl l区最高位纵隔气管前淋巴结区最高位纵隔气管前淋巴结 2 2区气管旁淋巴结区气管旁淋巴结 3 3区气管前、后或后纵隔（区气管前、后或后纵隔（3P3P）前纵隔（前纵隔（3a3a）淋巴结）淋巴结 4 4区气管与支气管交界处淋巴结区气管与支气管交界处淋巴结 5 5区主动脉或区主动脉或BotalloBotallo淋巴结淋巴结 6 6区主动脉（升主动脉）旁淋巴结区主动脉（升主动脉）旁淋巴结 7 7区隆突下淋巴结区隆突下淋巴结 8 8区隆突下食管旁淋巴结区隆突下食管旁淋巴结 9 9区下肺韧带淋巴结区下肺韧带淋巴结 1010区肺门（主支气管）淋巴结区肺门（主支气管）淋巴结 1111区肺叶间淋巴结区肺叶间淋巴结 1212区叶（上、中、下叶）支气管淋巴结区叶（上、中、下叶）支气管淋巴结 1313区段支气管淋巴结区段支气管淋巴结 1414区段以下远支气管淋巴结区段以下远支气管淋巴结 9古柏文档 Mountain and Dresler classifCT-based Definition of Thoracic Lymph Node Stations:CT-based Definition of Thoracic Lymph Node Stations:an atlas from the university of Michigan an atlas from the university of Michigan Olvier Chapet et al.Int.J.Radiation Oncology Biol.Phys.,Vol.63,No.1,pp.170178,200510古柏文档CT-based Definition of Thoraci&（highest mediastinal and upper paratracheal nodes）区：最高位纵隔气管前淋巴结区：左、右上气管旁淋巴结-区:一般常以胸骨颈静脉切迹为上界 主动脉弓为下界 左右界为纵隔胸膜 前界为左头臂动脉,右锁骨下动脉 右颈总动脉等大血管.后界为气管的后壁 注:在Mountain的淋巴结分区里,1R的下界定义为无名静脉横跨气管前,使得2区位于其下至主动脉弓的上缘的距离非常的短,故将 区-区合并为-区 11古柏文档&（highest mediastinal and u +12古柏文档 +12古柏文档区（区（prevascular nodes and retrotracheal nodes（图中未显示图中未显示）区：区：区：区：3区气管前、后或后纵隔（3P）和前纵隔（3A）淋巴结 3A 为气管前胸骨后淋巴结，上界：同12区(胸骨颈静脉切迹)下界：左：与区相连 右：上腔静脉前缘 两侧界：左右纵隔胸膜 前界：胸骨，锁骨头和肋骨 后界：12区前缘除外左锁骨下动脉 左颈总动脉，头臂(动脉)干3P：气管后淋巴结：气管后隆突上淋巴结 上界：同12区(胸骨颈静脉切迹)下界:气管隆突 前界：气管后壁 后界:椎体的前壁及外侧壁13古柏文档区（prevascular nodes and retro3A3P14古柏文档3A3P14古柏文档区（区（lower paratracheal nodes）区：左右下气管旁淋巴结区：左右下气管旁淋巴结区：左右下气管旁淋巴结区：左右下气管旁淋巴结 4R:4R:上界：上界：上界：上界：主动脉弓上缘层面 下界：右上叶支气管开口下界：右上叶支气管开口下界：右上叶支气管开口下界：右上叶支气管开口后界：后界：后界：后界：气管后壁前界:左颈总动脉和升主 动脉、主动脉弓前份后缘 4L:上界：上界：上界：上界：主动脉弓上缘层面 下界：下界：下界：下界：左上叶支气管开口 前界:左颈总动脉和升主 动脉、主动脉弓前份后缘 外界:主肺动脉窗层面以上位于主动脉内侧,主肺动脉窗层面位于动脉韧带内侧(左肺动脉干以上于升主动脉和降主动脉圆心连线内侧)左肺动脉干以下 则在左肺动脉干和左肺动脉内侧)。15古柏文档区（lower paratracheal nodes）16古柏文档16古柏文档区区subaortic(aortic-pulmonary window)区:主动脉下淋巴结 (又叫 主肺动脉窗淋巴结)上界:主动脉弓最大横截面以下 下界 右肺动脉横跨纵隔的最大横截面 内侧:左主支气管开口层面以上 与4L组淋巴结交界 外界:纵隔胸膜内 前界:出现右肺动脉前位于:升主动脉冠状面中平面延长线后,出现右肺动脉后局限于:肺动脉前缘 后界:在出现肺动脉前位于 降主动脉冠状面中平面延长线前,出现肺动脉后 则位于降主动脉前和肺动脉前 在出现右上肺静脉层面 后界延续到右上肺静脉前缘17古柏文档区 subaortic(aortic-pulmonar18古柏文档18古柏文档主肺动脉窗主肺动脉窗19古柏文档主肺动脉窗19古柏文档区与左喉返神经及膈神经的关系区与左喉返神经及膈神经的关系20古柏文档区与左喉返神经及膈神经的关系20古柏文档左右喉返神经与纵隔淋巴结的关系左右喉返神经与纵隔淋巴结的关系21古柏文档左右喉返神经与纵隔淋巴结的关系21古柏文档区（区（paraaortic nodes）区主动脉旁淋巴结 上界:主动脉弓上缘层面下界:与5区淋巴结同一水平前界和侧界:主动脉和主动脉弓外1cm 后界:在主动脉弓和升主动脉前1/2 肺动脉干前缘22古柏文档区（paraaortic nodes）区主动脉旁淋巴23古柏文档23古柏文档?24古柏文档?24古柏文档区区(subcarinal nodes)区隆突下淋巴结上界:在隆突下层面;下界:到隆突下约3 cm。前界:到左右主支气管前壁水平线 或右肺动脉后缘;后界:椎体前缘左外界:在奇静脉外缘;右外界:在右主支气管和右中间段支气 管内侧25古柏文档区(subcarinal nodes)区隆突下淋巴结26古柏文档26古柏文档区区（paraeosphageal nodes）区食管旁淋巴结 上界:同7区,是3P向下的延续;下界:沿食管至膈肌食管裂孔27古柏文档区（paraeosphageal nodes）区28古柏文档28古柏文档区（区（Pulmonary ligament nodes）区区区区 下肺韧带淋巴结 未提29古柏文档区（Pulmonary ligament nodes）区（区（hilar nodes）区（区（interlobar nodes）统称肺门淋巴结。上界为上叶支气管开口层面;下界为下叶段支气管开口以上。30古柏文档区（hilar nodes）区（interlob头臂静脉弓水平头臂静脉弓水平主动脉弓水平奇静脉弓水平隆突水平上叶支气管开口水平下叶支气管开口水平OR 隆突下cmRRRRLLL-左上叶支气管开口水平31古柏文档头臂静脉弓水平头臂静脉弓水平主动脉弓水平奇静脉弓水平隆突水平32古柏文档32古柏文档各区肿大淋巴结各区肿大淋巴结33古柏文档各区肿大淋巴结33古柏文档左上腔静脉左上腔静脉34古柏文档左上腔静脉34古柏文档主动脉瘤主动脉瘤35古柏文档主动脉瘤35古柏文档Prospective evaluation of computed Prospective evaluation of computed tomography andtomography andmediastinoscopy in mediastinal lymph node mediastinoscopy in mediastinal lymph node stagingstagingEur Respir J 1997;10:15471551n=100LNs larger than 1 cm were considered CT positive.36古柏文档Prospective evaluation of compMediastinal Lymph Node Staging With FDG-PET Scan in Mediastinal Lymph Node Staging With FDG-PET Scan in Patients With Potentially Operable Non-Patients With Potentially Operable Non-smallCellLungCancersmallCellLungCancer N=50 LNs larger than 1.5 cm were considered CT positiveChest 1997;112;1480-1486PET blinded to CT were significantly better(p=0.004):37古柏文档Mediastinal Lymph Node StagingMeta-Analysis of Positron Emission Tomographic and Meta-Analysis of Positron Emission Tomographic and Computed Tomographic Imaging in Detecting Computed Tomographic Imaging in Detecting Mediastinal Lymph Node Metastases in Non-small Cell Mediastinal Lymph Node Metastases in Non-small Cell Lung CancerLung CancerAnn Thorac Surg 2005;79:375 81 38古柏文档Meta-Analysis of Positron EmisMeta-Analysis of Positron Emission Tomographic and Computed Tomographic Imaging in Detecting Mediastinal Lymph Node Metastases in Non-small Cell Lung CancerAnn Thorac Surg 2005;79:375 81 FDG PETCTSensitivity range66%100%overall sensitivity83%Specificity range81%100%Overall specificity 92%20%81%44%100%59%78%39古柏文档Meta-Analysis of Positron EmisLymph Node Size and Metastatic Infiltration in Lymph Node Size and Metastatic Infiltration in Non-small Cell Lung CancerNon-small Cell Lung Cancer Chest 2003;123;463-467Nonmetastatic lymph nodesMetastatic lymph nodesn2486(86%)405(14%)size7.05 3.75 mm10.7 4.7 mm(p 0.005).size 10 mm1953(79%)170(44%)size 10-14 mm404 (16%)137(34%)size 15 mm130(5%)87(22%)256 patients2,891 lymph nodes Conclusion:Lymph node size is not a reliable parameter for the evaluation of metastatic involvement in patients with NSCLC.40古柏文档Lymph Node Size and MetastaticReal-time endobronchial ultrasound guidedReal-time endobronchial ultrasound guided transbronchial needle aspiration for sampling transbronchial needle aspiration for sampling mediastinal lymph nodesmediastinal lymph nodesThorax 2006;61;795-798;Sensitivity was 94%,specificity 100%,and the positive predictive value was 100%No complications occurred.41古柏文档Real-time endobronchial ultrasTHANK YOU 42古柏文档THANK YOU 42古柏文档
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